Provider Toolkit. Y0067_PR_Tlkt_0316 IA 03/09/2016

Transcription

1 Provider Toolkit Y0067_PR_Tlkt_0316 IA 03/09/2016 PFFS/PPO/TOHMO

2 TABLE OF CONTENTS Sample Letter from Physician to Patient...4 HEDIS Quick Reference Guide...5 Fax Cover Sheet...10 Preventive Checklist

3 Provider Toolkit Dear Healthcare Provider: We truly appreciate the care and support you provide to your patients who are Today s Options PFFS/PPO members. We know you are busy, which is why we have packaged some helpful forms and materials into this convenient Provider Toolkit. This kit contains updated versions of the following items: The Sample Letter from Physician to Patient For your convenience, we have included a pre-written sample letter that you can customize and send to your Today s Options PFFS/PPO/HMO patients who may be in need of medical services. To use this letter, save the file to your computer, type your updates into the editable fields, and print on your letterhead. It s that easy.* * Note: to remain compliant with Federal guidelines, the wording in the Sample Letter from Physician to Patient must remain as written. When printing, please be sure to include the tracking number located on the bottom left corner of the page. The HEDIS Quick Reference Guide Use this guide as a reference to code specific medical services. By coding properly, such as by using the appropriate ICD-10 codes for a patient s BMI index, you will help to reduce gaps through the claims system and reduce the potential for medical record requests. The Fax Cover Sheet Use this fax form to submit medical records for an annual physical exam or quality measure documentation on behalf of your Today s Options PFFS/PPO/HMO patient. The Preventive Checklist Form for Physician Offices This Checklist can be handed to your Today s Options PFFS/PPO/HMO patients. It will remind them to ask you about their needed medical services. We hope you find this Provider Toolkit to be helpful. If you should have any questions about how to use the items contained within this package, please contact a Today s Options PFFS/PPO/HMO Provider Relations representative at and leave a message. Your call will be returned promptly. Sincerely, Erin Page President, Medicare Advantage Today s Options PFFS/PPO/HMO Y0067_PR_Tlkt_0316 IA 03/09/2016 3

4 <Date> <Provider Name> <Provider Address> <Provider City, State, Zip Code> Dear <Member Name>: I am writing to let you know that, according to our records, you are due for the following important medical services checked below: Annual physical exam Diabetes Screenings (may include the following): Eye Exam Blood Sugar Check (HbA1c) Screening for Kidney Disease (Nephropathy) Cholesterol Check (LDL) Blood Pressure Check Medication Review Body Mass Index (BMI) Bone Mineral Density Test (Test for Osteoporosis) Mammogram Colorectal Screening Rheumatoid Arthritis Management Your health is very important to us, which is why we ask that you contact our office at <(xxx)xxx-xxxx> to schedule an appointment at your earliest convenience. If you have had any of these services at another location, please let us know when and where they were completed. We wish you good health. [<Provider signature>] [<Provider name>] Y0067_MBR_PQPP_MBRLetter_0316 IA 03/09/2016

5 PCP HEDIS QUICK REFERENCE GUIDE For Primary Care Providers HEDIS Measure Measure Requirements *Recommended Services Adult BMI Assessment (ABA) Breast Cancer Screening (BCS) Colorectal Cancer Screening (COL) Patients 18 to 74 years old have a documented weight and calculated BMI in 2015 or 2016 Female patients years old have a mammogram to screen for breast cancer every 2 ¼ years, 10/1/ /31/2016. Exclusion: Bilateral mastectomy any time during the patient s history through 12/31/2016 Patients age have a recommend screening for colorectal cancer in the appropriate timeframe Fecal Occult Blood Test (FOBT) in annually Flexible Sigmoidoscopy between every 5 years Colonoscopy between every ten years Not acceptable: digital rectal exams (DRE), FOBT tests performed in an office setting or performed on a sample collected via DRE. Exclusion: Colorectal cancer or total colectomy any time during the patient s history through 12/31/2016 BMI Z68.1, Z Z68.45 Mastectomy Z90.11 (Right) Z90.12 (Left) Z90.13 (Bilateral) Fecal Occult Blood Test CPT: 82270, HCPCS: G0328 Exclusion Colon Cancer C C18.9, C19, C20, C21.2, C21.8, C78.5, Z85.038, Z Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) Pharmacotherapy Management of COPD Exacerbation (PCE) Patients 40 years of age and older with a new diagnosis of COPD or newly active COPD on or between 7/1/2015 through 6/30/2016 Receive appropriate spirometry testing to confirm the diagnosis, 2 years prior to the COPD diagnosis through 6 months after the diagnosis Patients age 40 & older with a COPD exacerbation (as indicated by an acute inpatient discharge or ED encounter with a principal diagnosis of COPD) are dispensed appropriate medications Corticosteroid within 14 days of discharge/ed visit Bronchodilator within 30 days of discharge/ed visit Spirometry 94010, , 94060, 94070, 94375, Systemic Corticosteroids Glucocorticoids Bronchodilators Anticholinergic agents Beta 2-agonists Methylxanthines *These services/codes can be used for gap closure/exclusion but the list is not exhaustive. A coding manual should be referenced for more details. Y0067_PR_HEDISRefGuide_0216_IA 02/23/2016 5

6 HEDIS Measure Measure Requirements *Recommended Services *NEW Medication Management for People with Asthma (MMA) Controlling High Blood Pressure (CBP) * Medical Record Review only Persistence of Beta-Blocker Treatment after a Heart Attack (PBH) Statin Therapy for Patients with Cardiovascular Disease (SPC) Comprehensive Diabetes Care (CDC) HbA1c Test/Result Comprehensive Diabetes Care (CDC) BP Reading Patients age with persistent asthma are dispensed appropriate medications that they remained on during the treatment period Treatment period - The period of time beginning on the earliest prescription dispensing date through 12/31/2016 Patients with at least one outpatient visit with a diagnosis of hypertension from 1/1/2016 to 6/30/2016 have their blood pressure controlled during 2016 Documentation of HTN in the medical record anytime during the patient s history on or before 6/30/2016 and Most recent BP in 2016 after the diagnosis date is less than 140/90 mmhg Patients 18 and older who were hospitalized with a diagnosis of a MI and discharged from 7/1/2015 to 6/30/2016 receive persistent beta-blocker for at least 6 months post hospital discharge Patient males & females years of age identified as having clinical atherosclerotic cardiovascular disease (ASCVD) in 2014 or 2015 Received Statin Therapy at least one statin of high or moderate intensity during 2016 Statin Adherence remained on statin medication for at least 80% of the treatment period. Treatment period begins when statin prescribed till 12/31/2016. Patients years of age identified with diabetes (type I or II) in 2015 or 2016 Have a result of < 9.0% for their the most recent Hemoglobin A1c (HbA1c) test 2016 Patients years of age identified with diabetes (type I or II) in 2015 or 2016 Have a reading of <140/90 mm Hg for their most recent Blood Pressure reading in 2016 Asthma Medications Antiasthmatic combinations Antibody inhibitor Inhaled steroid combinations Inhaled corticosteroids Leukotriene modifiers Mast cell stabilizers Methylxanthines Short-acting, inhaled beta-2 agonists There is no administrative code that meets the requirement. The health plan will request the medical chart and the medical chart must contain documentation of the hypertension diagnosis from either An undated problem list Visit note on or before 6/30/2016 The Blood Pressure reading must come from a visit note after the diagnosis visit. Beta-Blocker Medications Noncardioselective beta-blockers Cardioselective beta-blockers Antihypertensive combinations Statin Medications High-intensity statin therapy Moderate-intensity statin therapy HgbA1c Test 83036, HgbA1c Result 3044F: < 7/0% 3045F :7.0% - 9.0%: 3046F: > 9.0% Systolic 3074F: < 130 mm Hg 3075F: 130 mm Hg mm Hg 3077F: > 140 mm Hg Diastolic 3078F: < 80 mm Hg 3079F: 80 mm Hg - 89 mm Hg 3080F: > 90 6

7 HEDIS Measure Measure Requirements *Recommended Services Comprehensive Diabetes Care (CDC) Eye Exam Comprehensive Diabetes Care (CDC) Nephropathy Management Statin Therapy for Patients with Diabetes (SPD) Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) Osteoporosis Management in Women Who Had a Fracture (OMW) Patients years of age identified with diabetes (type I or II) in 2015 or 2016 Have a retinal or dilated eye exam by an optometrist or ophthalmologist in 2016 (any result) Have a diabetic eye exam by an optometrist or ophthalmologist in 2015 that is negative for retinopathy An eye exam can be report by a PCP when there is documentation in the medical chart that an eye exam was performed/ reviewed by an eye care professional Patients years of age identified with diabetes (type I or II) in 2015 or 2016 receive one of the following medical attention for nephropathy in 2015 Urine Protein Test Nephropathy Treatment ACE/ARB dispensed CKD Stage 4, ESRD, Kidney Transplant Patients age with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) and who Received at least one statin medication during 2016 Remained on statin therapy for at least 80% of the treatment period. Treatment period begins when statin prescribed through 12/31/2016 Patients 18 and older who diagnosed with rheumatoid arthritis in 2016 Dispensed at least one prescription for a diseasemodifying anti-rheumatic drug (DMARD) by claim or by pharmacy data Women age who had a fracture on or between 7/1/2015 and 6/30/2016 Have a Bone Mineral Density (BMD) test within 6 months of fracture date Receive Osteoporosis medication within 6 months of fracture date Exclusion: Had (BMD) test during the 730 days (24 months) prior to the fracture Received Osteoporosis medication during the 365 days (12 months) prior to the fracture Retinal or dilated eye exam reported by a PCP 3072F: No evidence of retinopathy in F: Dilated retinal eye exam in F: Seven standard field stereoscopic photos with interpretation in F: Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results in 2016 Urine Protein Tests , 81005, , 84156, 3060F 3062F Nephropathy Treatment 3066F: Documentation of treatment for nephropathy (e.g. Dialysis, ESRD, CRF, ARF, or renal insufficiency) 4010F: ACE/ARP therapy prescribed or currently being taken High-intensity statin therapy Moderate-intensity statin therapy Low-intensity statin therapy DMARD 5-Aminosalicylates Alkylating agents Aminoquinolines Anti-rheumatics Immunomodulators Immunosuppressive agents Janus kinase (JAK) inhibitor Tetracyclines DMARD Medical claim J0129, J0135, J0717, J1438, J1600, J1602, J1745, J3262, J7502, J7515-J7518, J9250, J9260, J9310 Bone Mineral Density Test HCPCS: G0130 CPT: 76977, 77078, , Osteoporosis Therapies Biphosphonates Other Agents: Calcitonin, Denosumab, Raloxifene, Teriparatide Osteoporosis Therapies Medical Claim J0630, J0897, J1740, J3110, J3487, J3488, J3489, Q2051 7

8 HEDIS Measure Measure Requirements *Recommended Services Annual Monitoring for Patients on Persistent Medications (MPM) *NEW Medication Reconciliation Post-Discharge (MRP) Patients 18 and older taking ACE/ARB medications, digoxin, or diuretics, receive annual therapeutic monitoring. Any of the following during 2016 meet criteria: ACE/ARB Lab panel test Serum potassium test AND serum creatinine test Digoxin Lab panel test AND serum digoxin Serum potassium test AND serum creatinine test AND serum digoxin test Diuretics Lab panel test Serum potassium AND serum creatinine test Discharges from 1/1/ /1/2015 for patients 18 years of age and older for whom medications were reconciled the date of discharge through 30 days after discharge Discharge medications reconciled with the current medication list in outpatient medical record. Only documentation in the outpatient chart meets the intent of the measure, but an outpatient visit is not required Lab Panel 80047, 80048, 80050, 80053, Serum Potassium 80051, Serum Creatinine 82565, Digoxin The tests do not need to occur on the same service date, only within Reporting Code 1111F: Discharge medication reconciled with the current medication list in an outpatient medical record (can be submitted even if an office visit did not occur within the 30 days of discharge) Transitional Care Management Services 99495: Communication within 2 business days of discharge; by phone, , or in person and a face-to-face visit within 14 days of discharge. Potentially Harmful Drug-Disease Interactions (DDE) lower rate is better Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist or registered nurse To prevent patients 65 and older with history of falls, dementia, and chronic kidney disease in 2015 or 2016 from taking medications that may increase the risk for complications History of falls: Anticonvulsants, nonbenzodiazepine hypnotics, SSRIs, antiemetics, antipsychotics, benzodiazepines, or tricyclic antidepressants Dementia: Antiemetics, antipsychotics, benzodiazepines, tricyclic antidepressants, H 2 Receptor Antagonists, nonbenzodiazepine hypnotics or anticholinergic agents Chronic kidney disease: Cox-2 Selective NSAIDS or nonaspirin NSAIDS 99496: Communication within 2 business days of discharge; by phone, , or in person and a face-to-face visit within 7 days of discharge 8

9 HEDIS Measure Measure Requirements *Recommended Services Use of High-Risk Medication in the Elderly (DAE) lower rate is better To decrease the number of patients 66 and older who receive high-risk medications in 2016, 2 different criteria: At least one high-risk medication At least two different high-risk medications High-Risk Medications Anticholinergics (excludes TCAs), first-generation antihistamines Anticholinergics (excludes TCAs), anti-parkinson agents Antithrombotics Cardiovascular, alpha agonists, central Cardiovascular, other ( Disopyramide, Nifedipine, immediate release) Central nervous system, tertiary TCAs Central nervous system, barbiturates Central nervous system, vasodilators Central nervous system, other Endocrine system, estrogens with or without progestins; include only oral and topical patch products Endocrine system, sulfonylureas, long-duration Endocrine system, other Gastrointestinal system, other Pain medications, skeletal muscle relaxants Pain medications, other (Indomethacin, Ketorolac-includes parenteral, Meperidine, Pentazocine) High-Risk Medications With Days Supply Criteria >90 days Anti-infectives, other (Nitrofurantoin, Nitrofurantoin macrocrystals, Nitrofurantoin macrocrystals-monohydrate) Nonbenzodiazepine hypnotics ( Eszopiclone, Zaleplon, Zolpidem) Nitrofurantoin Prescription Days Supply Criteria High-Risk Medications With Average Daily Dose Criteria Reserpine >0.1 mg/day Digoxin >0.125 mg/day Doxepin >6 mg/day Non-Recommended PSA-Based Screening in Older Men (PSA) lower rate is better Antidepressant Medication Management (AMM) To perform PSA-based testing for men 70 years and older only when it is clinically appropriate. Prostate cancer diagnosis anytime in the patient s history. Dysplasia of the prostate in 2015 or A PSA test in 2015 where the laboratory data indicate an elevated result (>4.0ng/mL). Patients 18 years of age and older who were treated with antidepressant medication on or between 5/1/2015 and 3/30/2016, had a diagnosis of major depression and who remained on antidepressant medication treatment. Remain on an antidepressant medication for at least 84 days (12 weeks) Remain on an antidepressant medication for at least 180 days (6 months) 9 Prostate Cancer C61, D07.5, D40.0, Z15.03, Z85.46 Prostate Dysplasia - N42.3 Antidepressant Medications Miscellaneous antidepressants (Bupropion, Vilazodone, Vortioxetine) Monoamine oxidase inhibitors Phenylpiperazine antidepressants Psychotherapeutic combinations SNRI antidepressants SSRI antidepressants Tetracyclic antidepressants Tricyclic antidepressants

10 Fax Cover Sheet Medical Record Submission/Member List Please use this form when submitting medical records on behalf of your Today s Options PFFS/PPO/HMO patient, including documentation related to Annual Physical Exams and Quality Measures. Instructions Type directly into the open fields or print the form and complete it by hand. Check each box that corresponds to the record you are submitting. Fax or the cover sheet and medical records as indicated below. Physician Name: Contact Name: Total # of Pages: Phone Number: Member Name(s): First and last names/middle name or initial 1. Annual Physical Exam Quality Measure Documentation 2. Annual Physical Exam Quality Measure Documentation 3. Annual Physical Exam Quality Measure Documentation 4. Annual Physical Exam Quality Measure Documentation 5. Annual Physical Exam Quality Measure Documentation 6. Annual Physical Exam Quality Measure Documentation 7. Annual Physical Exam Quality Measure Documentation 8. Annual Physical Exam Quality Measure Documentation 9. Annual Physical Exam Quality Measure Documentation 10. Annual Physical Exam Quality Measure Documentation Submission of Medical Records Annual Physical (H&P) Program: Quality Measure Documentation (PQPP/HEDIS): Fax #: Fax #: RiskAdjustment@UniversalAmerican.com QualityMeasures@UniversalAmerican.com CONFIDENTIALITY NOTICE: The attached information to this facsimile transmission is CONFIDENTIAL and is intended only for the use of the recipient(s) identified above. It may contain confidential and protected health information subject to privacy regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If you are not the intended recipient or a person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. Y0067_PR_HPFax_0316 IA 03/21/

11 2016 Preventive Screenings Checklist Getting preventive care is one of the best ways to Live Healthy. Your plan covers the important screenings, tests, and immunizations included in this checklist. Talk to your doctor about which ones apply to you. Use this checklist throughout the year to record your exam dates, upcoming appointments and more. Screenings/Test/Treatment Recommended Frequency Date Completed Next Due Date Appointment Scheduled Doctor Contact Information Controlling Blood Pressure Annually Date: Time: Colorectal Cancer Screening: Fecal Occult Blood Test Comprehensive Diabetes Care (Includes the Retinal, Nephropathy, Hemoglobin A1c screenings) Annually Date: Time: Annually Date: Time: Breast Cancer Screening Annually Date: Time: Pap Test and Pelvic Exam Every 1 2 years Date: Time: Prostate Cancer Screening Annually Date: Time: Flu Vaccine (Nasal or Shot) Annually Date: Time: Medicare Wellness Visit Annually Date: Time: Bone Mass Measurement Every 2 years Date: Time: Colorectal Cancer Screening: Colonoscopy Pneumococcal Shot Every 2 10 years Date: Time: You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. Date: Time: If you have any questions about your plan, please call Member Services at the number listed on the back of your Member ID card. Today s Options PFFS, Today s Options PPO, and Today s Options HMO are Medicare Advantage plans with a Medicare contract. Enrollment in these plans depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year. Y0067_MBR_PREVCHKLIST_1015 IA 11/02/ TO-PRVCHCKLIST 2016